Alabama. Cancer Facts & Figures 2014

Transcription

1 Alabama Cancer Facts & Figures 2014

2 Alabama Department of Public Health Letter

3 American Cancer Society Letter Dear Alabamians, I am pleased to present Alabama Cancer Facts & Figures The American Cancer Society and the Alabama Department of Public Health have collaborated to produce this summary report about cancer in our state. Stakeholders in cancer control will use this document to measure progress in meeting the objectives outlined in the Alabama Comprehensive Cancer Control Coalition five-year plan. Cancer patients, health care and public health professionals, policy makers, advocates, news organizations, researchers, and the public will hopefully find this publication useful when seeking details and easy-to-read information about cancer in Alabama. This report shows the risk of developing several common cancers is falling and is a testament to the concerted work of many stakeholders across the state. Efforts to reduce smoking, increase screening, and improve awareness about cancer prevention have made an impact on cancer in Alabama. A large number of the cancer-related deaths could be prevented if people in Alabama lead a healthier lifestyle by avoiding tobacco products, maintaining a healthy weight and diet, and exercising regularly. The American Cancer Society and all of our partners are dedicated to improving the health of the people of Alabama. Please join us in the fight to help reduce the burden of cancer for all Alabamians and to eliminate disease as a cause of illness and death. Help us by living a healthy life, staying up to date on your cancer screenings, volunteering with the American Cancer Society, joining the Alabama Comprehensive Cancer Control Coalition, supporting cancer research, and being an advocate for cancer control in your community and across Alabama. Sincerely, Matt Allison Health System Manager American Cancer Society, Inc. Mid-South Division

4 Contents Cancer: Basic Facts 1 All Cancers 2 Incidence Rates 2 Mortality Rates 2 Trends 2 Selected Cancers 3 Lung Cancer 3 Colorectal Cancer 4 Melanoma 5 Prostate Cancer 6 Breast Cancer 7 Cervical Cancer 8 American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention 9 Screening Guidelines for the Early Detection of Cancer in Average-risk Asymptomatic People 10 Cancer Incidence Tables 11 Table 1. Alabama Cancer Incidence Rates and Counts, by Site and Sex, Combined 11 Table 2. Trends in Alabama Cancer Incidence, Selected Sites, Table 3. Alabama Cancer Incidence Rates and Counts, by County, Males and Females, All Races, Combined 13 Table 4. Alabama Cancer Incidence Rates and Counts, by County, Males, All Races, Combined 14 Table 5. Alabama Cancer Incidence Rates and Counts, by County, Females, All Races, Combined 15 Table 6. Alabama Cancer Incidence Rates and Counts, by County, Males and Females by Race, Combined 16 Table 7. Alabama Cancer Incidence Rates and Counts, by County, Males by Race, Combined 17 Table 8. Alabama Cancer Incidence Rates and Counts, by County, Females by Race, Combined 19 Cancer Mortality Tables 21 Table 9. Alabama Cancer Mortality Rates and Counts, by Site, Race, and Sex, Combined 21 Table 10. Trends in Alabama Cancer Mortality, Selected Sites, National Comparison Tables 24 Table 11. Alabama and United States Cancer Incidence Rates, by Site, Race, and Sex, Table 12. Alabama and United States Cancer Mortality Rates, by Site, Race, and Sex, Health Risk and Cancer Screening Behaviors Tables 25 Table 13. Percentage of Tobacco Use, Adults (2013) and High School Students (2013), Alabama and the US 25 Table 14. Percentage of Colorectal Cancer Screening, Adults 50 and Older, Alabama and the US, Table 15. Percentage of Breast Cancer Screening, Women 40 and Older, Alabama and the US, Table 16. Percentage of Prostate Cancer Screening, Men 50 and Older, Alabama and the US, Table 17. Percentage of Cervical Cancer Screening, Women 18 and Older, Alabama and the US, Table 18. Percentage of Fruit and Vegetable Intake, Adults 18 and Older, Alabama and the US, Table 19. Percentage of Physical Activity, Adults 18 and Older, Alabama and the US, Table 20. Percentage of Overweight, Adults 18 and Older, Alabama and the US, Sources 27 Technical Notes 27 American Cancer Society Quality of Life Programs 29 Visit the Alabama Statewide Cancer Registry website at adph.org/ascr for additional copies of the Alabama Cancer Facts & Figures 2014.

5 Cancer: Basic Facts What Is Cancer? Cancer is a group of diseases characterized by the uncontrolled growth and spread of abnormal cells. If the spread is not controlled, it can result in death. Cancer is caused by both external factors (tobacco, infectious organisms, chemicals, and radiation) and internal factors (inherited mutations, hormones, immune conditions, and mutations that occur from metabolism). These causal factors may act together or in sequence to initiate or promote the development of cancer. Ten or more years often pass between exposure to external factors and detectable cancer. Cancer is treated with surgery, radiation, chemotherapy, hormone therapy, immune therapy, and targeted therapy. 1 Can Cancer Be Prevented? A substantial proportion of cancers could be prevented. All cancers caused by cigarette smoking and heavy use of alcohol could be prevented completely. In 2014, almost 176,000 of the estimated 585,720 cancer deaths will be caused by tobacco use. In addition, the World Cancer Research Fund has estimated that up to one-third of the cancer cases that occur in economically developed countries like the US are related to overweight or obesity, physical inactivity, and/or poor nutrition, and thus could also be prevented. Certain cancers are related to infectious agents, such as hepatitis B virus (HBV), human papillomavirus (HPV), human immunodeficiency virus (HIV), and Helicobacter pylori (H. pylori). Many of these cancers could be prevented through behavioral changes or the use of protective vaccinations or antibiotic treatments. Many of the more than 3 million skin cancer cases that are diagnosed annually could be prevented by protecting skin from excessive sun exposure and avoiding indoor tanning. 1 Regular screening examinations by a health care professional can result in the detection and removal of precancerous growths, as well as the diagnosis of cancers at an early stage, when they are most treatable. Cancers of the cervix, colon, and rectum can be prevented by removal of precancerous tissue. Cancers that can be diagnosed early through screening include cancers of the breast, colon, rectum, cervix, prostate, oral cavity, and skin. A heightened awareness of changes in the breast or skin may also result in detection of these tumors at earlier stages. Who Is at Risk? Anyone can develop cancer. Since the risk of being diagnosed with cancer increases with age, most cases occur in adults who are middle-aged or older. About 77% of all cancers are diagnosed in people 55 and older. 1 Cancer researchers use the word risk in different ways, most commonly expressing risk as lifetime risk or relative risk. Lifetime risk refers to the probability that an individual will develop or die from cancer over the course of a lifetime. In the US, men have slightly less than a 1 in 2 lifetime risk of developing cancer; for women, the risk is a little more than 1 in 3. 1 Relative risk is a measure of the strength of the relationship between risk factors and a particular cancer. It compares the risk of developing cancer in people with a certain exposure or trait to the risk in people who do not have this characteristic. For example, male smokers are about 23 times more likely to develop lung cancer than nonsmokers, so their relative risk is 23. Women who have a first-degree relative (mother, sister, or daughter) with a history of breast cancer have about twice the risk of developing breast cancer compared to women who do not have a family history. 1 How Many New Cancer Cases Are Expected To Occur in 2014 in Alabama? In Alabama, there will be approximately 26,770 new cancer cases in 2014; approximately 73 people will hear that they have been diagnosed with cancer each day. 1 Estimated New Cancer Cases for Selected Cancer Sites, Alabama, 2014* Site New Cases All Sites 26,770 Female Breast 3,660 Uterine Cervix 210 Colon and Rectum 2,350 Uterine Corpus 650 Leukemia 690 Lung and Bronchus 4,160 Melanoma 1,320 Non-Hodgkin Lymphoma 990 Prostate 3,760 Urinary Bladder 990 *Rounded to the nearest 10. Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, Cancer Facts & Figures Atlanta: American Cancer Society. Alabama Cancer Facts & Figures

6 How Many People Are Expected to Die of Cancer in 2014 in Alabama? In Alabama, 10,510 people are expected to die of cancer this year. Lung cancer will account for 3,310 deaths, which is approximately 31% of all estimated cancer deaths in Alabama. 1 Estimated Cancer Deaths for Selected Cancer Sites, Alabama, 2014* Site Deaths All Sites 10,510 Brain/Nervous System 270 Female Breast 690 Colon and Rectum 950 Leukemia 410 Liver 350 Lung and Bronchus 3,310 Non-Hodgkin Lymphoma 310 Ovary 280 Pancreas 630 Prostate 540 Figure 1: All Sites Cancer Incidence and Mortality Rates*, by Sex and Race, Alabama Rate per 100, Males Incidence Females Black White Males Mortality Females *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Cancer Incidence ( ), Cancer Mortality ( ). Figure 2: Trends in Cancer Incidence Rates*, All Sites, Males and Females, Alabama, *Rounded to the nearest 10. Source: American Cancer Society, Cancer Facts & Figures Atlanta: American Cancer Society. All Cancers Rate per 100, Year Incidence Rates For both genders combined, Alabama s cancer incidence rate is higher than the US rate of (See Table 11, page 24.) Males in Alabama have a higher cancer incidence rate than females, with a rate of versus Among males, black males have a higher cancer incidence rate than white males, with a rate of versus Among females, white females have a higher cancer incidence rate than black females, with a rate of versus (See Figure 1 and Table 11, page 24.) Mortality Rates For both genders combined, Alabama s cancer mortality rate is higher than the US rate of ,4 Males in Alabama have a higher cancer mortality rate than females with a rate of versus Among males, black males have a higher cancer mortality rate than white males with a rate of versus Among females, black females have a higher cancer mortality rate than white females with a rate of versus (See Figure 1 and Table 12, page 24.) *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Trends Between 2008 and 2012, the percentage change for all sites cancer incidence in Alabama had an overall decrease of 7.0%; the annual percentage change during this time was -1.9%. 2 The decrease in cancer incidence was found to be statistically significant. (See Figure 2 and Table 2, page 12.) Between 2008 and 2012, the percentage change for all sites cancer mortality in Alabama had an overall decrease of 6.1%; the annual percentage change during this time was -1.7%. 2 The decrease in cancer mortality was found to be statistically significant. (See Figure 3 and Table 10, page 23.) 2 Alabama Cancer Facts & Figures 2014

7 Figure 3: Trends in Cancer Mortality Rates*, All Sites, Males and Females, Alabama, Rate per 100, Year 2011 *Per 100,000, age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Figure 5: Trends in Lung Cancer Incidence and Mortality Rates*, Males and Females, Alabama, Rate per 100, Year Incidence 2011 Mortality 2012 *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Selected Cancers Lung Cancer 2014 Estimates In 2014, an estimated 4,160 new cases of lung and bronchus cancer and approximately 3,310 deaths from lung and bronchus cancer are expected to occur in Alabama. 1 Incidence Rates For both genders combined, the lung cancer incidence rate in Alabama is 74.5 significantly higher than the US rate of (See Table 11, page 24.) Males in Alabama have a higher lung cancer incidence rate than females, with a rate of versus Among males in Alabama, black males have a higher lung cancer incidence rate than white males, with a rate of Figure 4: Lung Cancer Incidence and Mortality Rates*, by Sex and Race, Alabama Rate per 100, Males Incidence Females Black White Males Mortality Females *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Cancer Incidence ( ), Cancer Mortality ( ) versus Among females in Alabama, white females have a higher lung cancer incidence rate than black females, with a rate of 59.3 versus (See Figure 4 and Table 11, page 24.) Mortality Rates For both genders combined, the lung cancer mortality rate in Alabama is 60.0 significantly higher than the US rate of ,4 Males in Alabama have a higher lung cancer mortality rate than females, with a rate of 86.8 versus Among males in Alabama, black males have a higher lung cancer mortality rate than white males, with a rate of 91.1 versus Among females in Alabama, white females have a higher lung cancer mortality rate than black females, with a rate of 43.5 versus (See Figure 4 and Table 12, page 24.) Trends Between 2008 and 2012, the percentage change for lung cancer incidence in Alabama had an overall decrease of 10.9%; the annual percentage change during this time was -2.8%. 2 For lung cancer mortality between 2008 and 2012, the percentage change had an overall decrease of 8.1%; the annual percentage change during this time was -2.5%. 2 Although the decrease in incidence was found to be statistically significant, the decrease in mortality was not statistically significant. (See Figure 5 and Table 2, page 12, and Table 10, page 23.) Risk Factors Cigarette smoking is by far the most important risk factor for lung cancer. Risk increases with quantity and duration of cigarette consumption. Cigar and pipe smoking also increase risk. Other risk factors include occupational or environmental exposure to secondhand smoke, radon, asbestos (particularly among smokers), certain metals (chromium, cadmium, arsenic), some organic chemicals, radiation, air pollution, diesel exhaust, and paint. 1 Genetic susceptibility can also play a contributing role in the development of lung cancer, especially in those who develop lung cancer at a younger age. 1 Alabama Cancer Facts & Figures

8 Tobacco Use Alabama adults and Alabama youth have higher rates of cigarette smoking than the national averages. While 21.5% of Alabama adults and 18.0% of Alabama youth smoke, the national averages are 19.0% and 15.7%, respectively. 5 Adults with low levels of education have the highest rates of cigarette smoking in Alabama. 5 (See Table 13, page 25, for additional information on smoking rates in Alabama and the US.) Colorectal Cancer 2014 Estimates In 2014, an estimated 2,350 new cases of colorectal cancer and approximately 950 colorectal cancer deaths are expected to occur in Alabama. 1 Incidence Rates For both genders combined, the colorectal cancer incidence rate in Alabama is 46.5 significantly higher than the US rate of (See Table 11, page 24.) Males in Alabama have a higher colorectal cancer incidence rate than females, with a rate of 56.0 versus Among males in Alabama, black males have a higher colorectal cancer incidence rate than white males, with a rate of 67.9 versus Among females in Alabama, black females have a higher colorectal cancer incidence rate than white females, with a rate of 46.8 versus (See Figure 6 and Table 11, page 24.) Mortality Rates For both genders combined, the colorectal cancer mortality rate in Alabama is 17.8 significantly higher than the US rate of ,4 Males in Alabama have a higher colorectal cancer mortality rate than females, with a rate of 22.3 versus Figure 6: Colorectal Cancer Incidence and Mortality Rates*, by Sex and Race, Alabama Rate per 100, Males Incidence Females Black White Males Mortality Females *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Cancer Incidence ( ), Cancer Mortality ( ) Figure 7: Trends in Colorectal Cancer Incidence and Mortality Rates*, Males and Females, Alabama, Rate per 100, Year Incidence 2011 Mortality 2012 *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Among males in Alabama, black males have a higher colorectal cancer mortality rate than white males, with a rate of 32.1 versus Among females in Alabama, black females have a higher colorectal cancer mortality rate than white females, with a rate of 20.1 versus (See Figure 6 and Table 12, page 24.) Trends Between 2008 and 2012, the percentage change for colorectal cancer incidence in Alabama had an overall decrease of 13.5%; the annual percentage change during this time was -3.9%. 2 For colorectal cancer mortality between 2008 and 2012, the percentage change had an overall decrease of 13.9%; the annual percentage change during this time was -3.7%. 2 The trend in colorectal cancer mortality was statistically significant, and the trend in incidence was borderline significant. (See Figure 7 and Table 2, page 12, and Table 10, page 23.) Risk Factors The risk of colorectal cancer increases with age; 90% of cases are diagnosed in individuals over 50 years of age. 1 Risk is also increased by certain inherited genetic mutations (familial adenomatous polyposis [FAP] and hereditary non-polyposis colorectal cancer [HNPCC]), a personal or family history of colorectal cancer and/or polyps, or a personal history of chronic inflammatory bowel disease. 1 Several modifiable factors are associated with an increased risk of colorectal cancer. These include smoking, physical inactivity, obesity, heavy alcohol consumption, a diet high in red or processed meat, and inadequate intake of fruits and vegetables. 1 Early Detection Beginning at age 50, men and women who are at average risk for developing colorectal cancer should begin screening. Screening can result in the detection and removal of colorectal polyps before they become cancerous, as well as detect cancers at an early stage. 1 When colorectal cancers are detected at an early, localized stage, the 5-year survival rate is 90%; however, 4 Alabama Cancer Facts & Figures 2014

9 only 40% of colorectal cancer cases are diagnosed at this stage, mostly due to underuse of screening. 1 After the cancer has spread regionally to involve adjacent organs or lymph nodes, the 5-year survival drops to 70%. For people with distant stage diagnosis, the 5-year survival rate is 13%. 1 For all adults 50 years of age and older, Alabama adults have similar rates of colorectal cancer screening compared to the national average. 5 Adults with low education have the lowest colorectal cancer screening rates of all genders and races in Alabama. 5 (See page 10 for the American Cancer Society s screening guidelines for the early detection of colorectal cancer and Table 14, page 25, for more information on colorectal cancer screening rates in Alabama and the US.) Melanoma 2014 Estimates In 2014, it is estimated that 1,320 new cases of melanoma will occur in Alabama. 1 Incidence Rates For both genders combined, the melanoma incidence rate in Alabama is 21.0 significantly higher than the US rate of (See Table 11, page 24.) Males in Alabama have a higher melanoma incidence rate than females, with a rate of 28.2 versus Among males in Alabama, white males have a significantly higher melanoma incidence rate than black males, with a rate of 35.1 versus Among females in Alabama, white females have a significantly higher melanoma incidence rate than black females, with a rate of 21.1 versus (See Figure 8 and Table 11, page 24.) Figure 8: Melanoma Incidence and Mortality Rates*, by Sex and Race, Alabama Rate per 100, Males Incidence Females Black White Males Mortality Females *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Cancer Incidence ( ), Cancer Mortality ( ) Figure 9: Trends in Melanoma Incidence and Mortality Rates*, Males and Females, Alabama, Rate per 100, Year Incidence 2011 Mortality 2012 *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Mortality Rates For both genders combined, the melanoma mortality rate in Alabama is 2.8 roughly the same as the US rate of ,4 Males in Alabama have a higher melanoma mortality rate than females, with a rate of 4.4 versus Among males in Alabama, white males have a higher melanoma mortality rate than black males, with a rate of 5.3 versus Among females in Alabama, white females have a higher melanoma mortality rate than black females, with a rate of 2.2 versus (See Figure 8 and Table 12, page 24.) Trends Between 2008 and 2012, the percentage change for melanoma incidence in Alabama had an overall increase of 5.9%; the annual percentage change during this time was 0.3%. 2 For melanoma mortality between 2008 and 2012, the percentage change had an overall increase of 10.7%; however, the annual percentage change during this time was -0.5%. 2 Neither trend was statistically significant. (See Figure 9 and Table 2, page 12, and Table 10, page 23.) Risk Factors Major risk factors for melanoma include a personal or family history of melanoma and the presence of atypical moles or a large number of moles (greater than 50). Other risk factors for all types of skin cancer include sun sensitivity (sunburning easily, difficulty tanning, natural blond or red hair color); a history of excessive sun exposure, including sunburns; use of tanning booths; diseases that suppress the immune system; and a past history of basal cell or squamous cell skin cancers. 1 Early Detection The best way to detect skin cancer early is to recognize changes in skin growths or the appearance of new growths. 1 Adults should undergo regular dermatologic assessment and thoroughly examine their skin on a regular basis. 1 New or unusual lesions or a progressive change in a lesion s appearance size, Alabama Cancer Facts & Figures

10 shape, or color, etc. should be evaluated promptly by a physician. 1 A simple ABCD rule outlines the warning signals of the most common type of melanoma: A is for asymmetry (one half of the mole does not match the other half); B is for border irregularity (the edges are ragged, notched, or blurred); C is for color (the pigmentation is not uniform, with variable degrees of tan, brown, or black); D is for diameter greater than 6 millimeters (about the size of a pencil eraser). 1 If detected at its earliest stages and treated properly, melanoma is highly curable. 1 When detected at a localized stage, the 5-year survival rate is 98%; the 5-year survival rates for regional and distant stage diseases are 62% and 16%, respectively. 1 Prostate Cancer 2014 Estimates In 2014, an estimated 3,760 new cases of prostate cancer and approximately 540 prostate cancer deaths are expected to occur in Alabama. 1 Incidence Rates The prostate cancer incidence rate in Alabama is significantly higher than the US rate of (See Table 11, page 24.) Black males in Alabama have a significantly higher prostate cancer incidence rate than white males, with a rate of versus (See Figure 10 and Table 11, page 24.) Mortality Rates The prostate cancer mortality rate in Alabama is 28.6 significantly higher than the US rate of ,4 Black males in Alabama have a significantly higher prostate cancer mortality rate than white males with a rate of 63.8 versus (See Figure 10 and Table 12, page 24.) Figure 10: Prostate Cancer Incidence and Mortality Rates*, Males, by Race, Alabama Rate per 100, Incidence Black White Mortality *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Cancer Incidence ( ), Cancer Mortality ( ) Figure 11: Trends in Prostate Cancer Incidence and Mortality Rates*, Males, Alabama, Rate per 100, Year Incidence 2011 Mortality 2012 *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Trends Between 2008 and 2012, the percentage change for prostate cancer incidence in Alabama had an overall decrease of 20.4%; the annual percentage change during this time was -5.1% and was statistically significant. 2 For prostate cancer mortality between 2008 and 2012, the percentage change had an overall decrease of 20.7%; the annual percentage change during this time was -4.8% but was not statistically significant. 2 (See Figure 11 and Table 2, page 12, and Table 10, page 23.) Risk Factors Age, ethnicity, and family history are well-established risk factors for prostate cancer. 1 About 60% of all prostate cancer cases are diagnosed in men 65 years of age and older, and 97% occur in men 50 and older. African American men and Caribbean men of African descent have the highest prostate cancer incidence rates in the world. 1 Genetic studies suggest that strong familial disposition may account for 5-10% of prostate cancer cases. Studies suggest that a diet high in processed meat or dairy foods may be a risk factor, and obesity appears to increase risk of aggressive prostate cancer. 1 Early Detection The American Cancer Society recommends that beginning at age 50, men who have at least a 10-year life expectancy should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the potential benefits, risks, and uncertainties associated with screening. Prostate cancer screening should not occur without an informed decisionmaking process. The 5-year survival rate for prostate cancer is almost 100% when the cancer is diagnosed and treated at the local and regional stages. 1 Males in Alabama have higher rates of PSA screening than the US averages. 8 Males of low education have the lowest rates of PSA screening of all groups. 8 (See page 10 for the American Cancer Society s screening guidelines concerning the early detection of prostate cancer and Table 16, 6 Alabama Cancer Facts & Figures 2014

11 page 26, for more information on prostate cancer screening rates in Alabama and the US.) Breast Cancer 2014 Estimates In 2014, an estimated 3,660 new cases of female breast cancer and approximately 690 female breast cancer deaths are expected to occur in Alabama. 1 Incidence Rates The female breast cancer incidence rate in Alabama is significantly lower than the US rate of (See Table 11, page 24.) Black females in Alabama have a significantly higher breast cancer incidence rate than white females, with a rate of versus (See Figure 12 and Table 11, page 24.) Mortality Rates The female breast cancer mortality rate in Alabama is 23.4 marginally higher than the US rate of ,4 Black females in Alabama have a significantly higher breast cancer mortality rate than white females, with a rate of 30.9 versus (See Figure 12 and Table 12, page 24.) Trends Between 2008 and 2012, the percentage change for breast cancer incidence in Alabama had an overall decrease of 2.1%; the annual percentage change during this time was -0.7%. 2 For breast cancer mortality between 2008 and 2012, the percentage change had an overall decrease of 2.3%; the annual percentage change during this time was -0.8%. 2 Neither trend was statistically significant. (See Figure 13 and Table 2, page 12, and Table 10, page 23.) Figure 12: Breast Cancer Incidence and Mortality Rates*, Females, by Race, Alabama Rate per 100, Incidence Black White Mortality *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Cancer Incidence ( ), Cancer Mortality ( ) Figure 13: Trends in Breast Cancer Incidence and Mortality Rates*, Females, Alabama, Rate per 100, Year Incidence 2011 Mortality 2012 *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Risk Factors Aside from being female, age is the most important factor affecting breast cancer risk. Risk is also increased by inherited genetic mutations in the BRCA1 and BRCA2 genes, a personal or family history of breast cancer, high breast tissue density, biopsy-confirmed hyperplasia, high bone mineral density, and high-dose radiation to the chest, typically related to a medical procedure. 1 Reproductive factors that increase breast cancer risk include a long menstrual history (menstrual periods that start early and/or end late in life), never having children, recent use of oral contraceptives, and having one s first child after age Potentially modifiable risk factors include weight gain after age 18, being overweight or obese (for post-menopausal breast cancer), use of combined estrogen and progestin menopausal hormone therapy, physical inactivity, and alcohol consumption. 1 Early Detection Mammography can detect breast cancer at an early stage, when treatment is more effective. 1 Steady declines in breast cancer mortality among women since 1989 have been attributed to a combination of early detection and improvements in treatment. When breast cancers are detected and diagnosed at the localized stage, the relative 5-year survival rate is 99%, compared to a rate of only 24% for breast cancers detected at the distant stage. 1 Alabama females have a slightly higher rate of mammography screening than the US average 74.3% of Alabama females have had a mammogram in the past two years, compared to 74.0% of US females. 5 Black females in Alabama have a higher rate of mammography screening than white females. 5 Females with a low education have the lowest rate of mammography of all age groups and races. 5 (See page 10 for the American Cancer Society s screening guidelines for the early detection of breast cancer and Table 15, page 25, for more information on breast cancer screening rates in Alabama and the US.) Alabama Cancer Facts & Figures

12 Cervical Cancer 2014 Estimates In 2014, it is estimated that 210 new cases of cervical cancer will occur in Alabama. 1 Incidence Rates The cervical cancer incidence rate in Alabama is 8.6 significantly higher than the US rate of (See Table 11, page 24.) Black females in Alabama have a higher cervical cancer incidence rate than white females, with a rate of 10.4 versus (See Figure 14 and Table 11, page 24.) Mortality Rates The cervical cancer mortality rate in Alabama is 3.0 significantly higher than the US rate of ,4 Black females in Alabama have a higher cervical cancer mortality rate than white females, with a rate of 5.1 versus (See Figure 14 and Table 12, page 24.) Trends Between 2008 and 2012, the percentage change for cervical cancer incidence in Alabama had an overall increase of 16.5%; the annual percentage change during this time was 1.8%. 2 For cervical cancer mortality between 2008 and 2012, the percentage change had an overall decrease of 9.5%; the annual percentage change during this time was -0.2%. 2 Neither trend was statistically significant. (See Figure 15 and Table 2, page 12, and Table 10, page 23.) Figure 14: Cervical Cancer Incidence and Mortality Rates*, Females, by Race, Alabama Rate per 100, Incidence Black White Mortality *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Cancer Incidence ( ), Cancer Mortality ( ) Figure 15: Trends in Cervical Cancer Incidence and Mortality Rates*, Females, Alabama, Rate per 100, Year Incidence 2011 Mortality 2012 *Malignant only, per 100,000 and age-adjusted to the 2000 US standard population. Source: Alabama Statewide Cancer Registry, Risk Factors The primary cause of cervical cancer is infection with certain types of human papillomavirus (HPV). 1 Women who begin having sex at an early age or who have many sexual partners are at increased risk for HPV and cervical cancer. However, a woman may be infected with HPV even if she has had only one sexual partner. Persistence of the infection and progression to cancer may be influenced by factors such as immunosuppression, high parity (number of childbirths), and cigarette smoking. Long-term use of oral contraceptives is also associated with increased risk of cervical cancer. 1 Prevention The FDA has approved two vaccines (Gardasil and Cervarix) for use in females ages 9 to 26 for the prevention of the most common HPV infections that cause cervical cancer. The vaccines cannot protect against established infections, nor do they protect against all HPV types. Screening can prevent cervical cancer by detecting precancerous lesions. As screening has become more common, preinvasive lesions of the cervix are detected far more frequently than invasive cancer. The Pap test is the most widely used cervical cancer screening method. Early Detection The Pap test is a simple procedure in which a small sample of cells is collected from the cervix and examined. 1 When detected at a localized stage, the 5-year survival rate for invasive cervical cancer is 91%. 1 As a group, females 18 years of age and older in Alabama have a slightly higher rate of cervical cancer screening than the US average. 5 Females of low education have the lowest rate of screening for all ages and races. 5 (See page 10 for the American Cancer Society s screening guidelines for the early detection of cervical cancer and Table 17, page 26, for more information on cervical cancer screening rates in Alabama.) 8 Alabama Cancer Facts & Figures 2014

13 American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention Individual Choices Achieve and maintain a healthy weight throughout life. Be as lean as possible throughout life without being underweight. Avoid excessive weight gain at all ages. For those who are overweight or obese, losing even a small amount of weight has health benefits and is a good place to start. Get regular physical activity and limit intake of high-calorie foods and drinks as keys to help maintain a healthy weight. Adopt a physically active lifestyle. Adults: Engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity activity each week (or a combination of these), preferably spread out over the week. Children and teens: Engage in at least 1 hour of moderate- to vigorous-intensity activity each day, with vigorous activity on at least 3 days per week. Limit sedentary behavior such as sitting, lying down, watching TV and other forms of screen-based entertainment. Doing some physicial activity above usual activities can have many health benefits. Eat a healthy diet, with an emphasis on plant foods. Choose foods and beverages in amounts that help achieve and maintain a healthy weight. Eat at least 2½ cups of vegetables and fruits each day. Choose whole grains instead of refined-grain products. Limit consumption of processed and red meats. If you drink alcoholic beverages, limit consumption. Drink no more than 1 drink per day for women or 2 per day for men. Community Action Public, private, and community organizations should work together at national, state, and local levels to apply policy and environmental changes that: Increase access to affordable, healthy food in communities, places of work, and schools, and decrease access to and marketing of foods and drinks of low nutritional value, particularly to youth. Provide safe, enjoyable, and accessible environments for physical activity in schools and workplaces and for transportation and recreation in communities. Alabama Cancer Facts & Figures

14 Screening Guidelines for the Early Detection of Cancer in Average-risk Asymptomatic People Cancer Site Population Test or Procedure Frequency Breast Women, ages, 20+ Breast self-examination (BSE) It is acceptable for women to choose not to do BSE or to do BSE regularly (monthly) or irregularly. Beginning in their early 20s, women should be told about the benefits and limitations of BSE. Whether or not a woman ever performs BSE, the importance of prompt reporting of any new breast symptoms to a health professional should be emphasized. Women who choose to do BSE should receive instruction and have their technique reviewed on the occasion of a periodic health examination. Clinical breast examination (CBE) For women in their 20s and 30s, it is recommended that CBE be part of a periodic health examination, preferably at least every 3 years. Asymptomatic women ages 40 and over should continue to receive a CBE as part of a periodic health examination, preferably annually. Mammography Begin annual mammography at age 40.* Cervix Women, ages Pap test & HPV DNA test Cervical cancer screening should begin at age 21. For women ages 21-29, screening should be done every 3 years with conventional or liquid-based Pap tests. For women ages 30-65, screening should be done every 5 years with both the HPV test and the Pap test (preferred), or every 3 years with the Pap test alone (acceptable). Women ages 65+ who have had 3 consecutive negative Pap tests or 2 consecutive negative HPV and Pap tests within the past 10 years, with the most recent test occurring within 5 years, and women who have had a total hysterectomy should stop cervical cancer screening. Women should not be screened annually by any method at any age. Colorectal Men and women, ages 50+ Fecal occult blood test (FOBT) with at least 50% test sensitivity for cancer, or fecal immunochemical test (FIT) with at least 50% test sensitivity for cancer, or Annual, starting at age 50. Testing at home with adherence to manufacturer s recommendation for collection techniques and number of samples is recommended. FOBT with the single stool sample collected on the clinician s fingertip during a digital rectal examination is not recommended. Guaiac-based toilet bowl FOBT tests also are not recommended. In comparison with guaiac-based tests for the detection of occult blood, immunochemical tests are more patientfriendly, and are likely to be equal or better in sensitivity and specificity. There is no justification for repeating FOBT in response to an initial positive finding. Stool DNA test, or Every 3 years, starting at age 50. Flexible sigmoidoscopy (FSIG), or Double-contrast barium enema (DCBE), or Every 5 years, starting at age 50. FSIG can be performed alone, or consideration can be given to combining FSIG performed every 5 years with a highly sensitive gfobt or FIT performed annually. Every 5 years, starting at age 50. Colonoscopy Every 10 years, starting at age 50. CT Colonography Every 5 years, starting at age 50. Endometrial Women, at menopause At the time of menopause, women at average risk should be informed about risks and symptoms of endometrial cancer and strongly encouraged to report any unexpected bleeding or spotting to their physicians. Lung Current or former smokers ages in good health with at least a 30 pack-year history Low-dose helical CT (LDCT) Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with apparently healthy patients ages who have at least a 30 pack-year smoking history, and who currently smoke or have quit within the past 15 years. A process of informed and shared decision making with a clinician related to the potential benefits, limitations, and harms associated with screening for lung cancer with LDCT should occur before any decision is made to initiate lung cancer screening. Smoking cessation counseling remains a high priority for clinical attention in discussions with current smokers, who should be informed of their continuing risk of lung cancer. Screening should not be viewed as an alternative to smoking cessation. Prostate Men, ages 50+ Digital rectal examination (DRE) and prostate-specific antigen test (PSA) Men who have at least a 10-year life expectancy should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the potential benefits, risks, and uncertainties associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision-making process. Cancerrelated checkup Men and women, ages 20+ On the occasion of a periodic health examination, the cancer-related checkup should include examination for cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity, and skin, as well as health counseling about tobacco, sun exposure, diet and nutrition, risk factors, sexual practices, and environmental and occupational exposures. *Beginning at age 40, annual clinical breast examination should be performed prior to mammography. 10 Alabama Cancer Facts & Figures 2014

15 Cancer Incidence Tables Table 1. Alabama Cancer Incidence Rates and Counts, by Site and Sex, Combined Males Rate Count Females Rate Count All Sites ,287 All Sites ,993 Oral Cavity and Pharynx ,735 Oral Cavity and Pharynx 7.0 1,984 Digestive System ,759 Digestive System ,373 Esophagus 8.6 2,049 Esophagus Stomach 8.7 1,925 Stomach 4.6 1,315 Small Intestine Small Intestine Colon and Rectum ,970 Colon and Rectum ,544 Colon Excluding Rectum ,250 Colon Excluding Rectum ,884 Rectum ,720 Rectum 9.3 2,660 Anus, Anal Canal, and Anorectum Anus, Anal Canal, and Anorectum Liver and Intrahepatic Bile Duct 8.9 2,108 Liver and Intrahepatic Bile Duct Gallbladder Gallbladder Pancreas ,119 Pancreas ,989 Other Digestive Organs Other Digestive Organs Respiratory System ,826 Respiratory System ,385 Larynx 9.1 2,184 Larynx Lung and Bronchus ,326 Lung and Bronchus ,677 Bones and Joints Bones and Joints Soft Tissue Including Heart Soft Tissue Including Heart Skin (Excluding Basal and Squamous) ,197 Skin (Excluding Basal and Squamous) ,249 Melanoma of the Skin ,819 Melanoma of the Skin ,982 Other Non-Epithelial Skin Other Non-Epithelial Skin Breast Breast ,687 Female Genital System * * Female Genital System ,793 Cervix Uteri * * Cervix Uteri 8.5 2,101 Corpus and Uterus, NOS * * Corpus and Uterus, NOS ,234 Corpus Uteri * * Corpus Uteri ,009 Uterus, NOS * * Uterus, NOS Ovary * * Ovary ,400 Vagina * * Vagina Vulva * * Vulva Other Female Genital Organs * * Other Female Genital Organs Male Genital System ,126 Male Genital System * * Prostate ,893 Prostate * * Testis Testis * * Penis Penis * * Other Male Genital Organs Other Male Genital Organs * * Urinary System ,335 Urinary System ,491 Urinary Bladder ,116 Urinary Bladder 7.5 2,214 Kidney and Renal Pelvis ,965 Kidney and Renal Pelvis ,137 Ureter Ureter Other Urinary Organs Other Urinary Organs Eye and Orbit Eye and Orbit Brain and Other Nervous System 7.9 1,821 Brain and Other Nervous System 5.7 1,514 Endocrine System 4.9 1,147 Endocrine System ,093 Thyroid Thyroid ,926 Other Endocrine Including Thymus Other Endocrine Including Thymus Lymphoma ,114 Lymphoma ,447 Hodgkin Lymphoma Hodgkin Lymphoma Non-Hodgkin Lymphoma ,498 Non-Hodgkin Lymphoma ,936 Myeloma 7.6 1,709 Myeloma 5.0 1,448 Leukemia ,252 Leukemia 9.2 2,527 Lymphocytic Leukemia 7.2 1,594 Lymphocytic Leukemia 4.0 1,119 Acute Lymphocytic Leukemia Acute Lymphocytic Leukemia Chronic Lymphocytic Leukemia 5.3 1,162 Chronic Lymphocytic Leukemia Myeloid and Monocytic Leukemia 6.5 1,419 Myeloid and Monocytic Leukemia 4.4 1,183 Acute Myeloid Leukemia Acute Myeloid Leukemia Chronic Myeloid Leukemia Chronic Myeloid Leukemia Other Leukemia Other Leukemia Miscellaneous ,258 Miscellaneous ,742 Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. Rates and counts are for malignant cases only, with the exception of urinary bladder and groups that contain urinary bladder. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures

16 Table 2. Trends in Alabama Cancer Incidence, Selected Sites, Females Breast P-Value Cervix P-Value Rate/Trend SE Lower CI Upper CI Rate/Trend SE Lower CI Upper CI Total PC -2.1 Total PC 16.5 Total APC Total APC Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Males Males and Females Prostate P-Value All Sites P-Value Rate/Trend SE Lower CI Upper CI Rate/Trend SE Lower CI Upper CI Total PC Total PC -7.0 Total APC -5.1* Total APC -1.9* Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Males and Females Colorectal P-Value Lung P-Value Rate/Trend SE Lower CI Upper CI Rate/Trend SE Lower CI Upper CI Total PC Total PC Total APC Total APC -2.8* Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Males and Females Melanoma P-Value Oral P-Value Rate/Trend SE Lower CI Upper CI Rate/Trend SE Lower CI Upper CI Total PC 5.9 Total PC 0.3 Total APC Total APC Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard; Confidence intervals are 95% for rates and trends. Rates are for malignant cases only, with the exception of All Sites which includes bladder cancer in situ. Percent changes were calculated using 1 year for each end point; APCs were calculated using weighted least squares method. *The APC is significantly different from zero (p<0.05). Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures 2014

17 Table 3. Alabama Cancer Incidence Rates and Counts, by County, Males and Females, All Races, Combined All Sites Lung Colorectal Oral Melanoma Rate Count Rate Count Rate Count Rate Count Rate Count Alabama , , , , ,801 Autauga , Baldwin , , Barbour , Bibb , Blount , Bullock ^ ^ Butler , Calhoun , , Chambers , Cherokee , Chilton , Choctaw Clarke , Clay Cleburne Coffee , Colbert , Conecuh Coosa ^ ^ Covington , Crenshaw Cullman , Dale , Dallas , DeKalb , Elmore , Escambia , Etowah , , Fayette , Franklin , Geneva , Greene ^ ^ ^ ^ Hale Henry , Houston , Jackson , Jefferson , , , ,193 Lamar Lauderdale , Lawrence , Lee , Limestone , Lowndes ^ ^ ^ ^ Macon , ^ ^ Madison , , , Marengo , Marion , Marshall , Mobile , , , Monroe , Montgomery , , , Morgan , , Perry ^ ^ ^ ^ Pickens , Pike , Randolph , Russell , St. Clair , Shelby , , Sumter ^ ^ Talladega , Tallapoosa , Tuscaloosa , , Walker , Washington Wilcox ^ ^ Winston , Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. Rates are for malignant cases only, except for All Sites which contains in situ bladder cases. ^ Statistic not displayed due to fewer than 15 cases. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures

18 Table 4. Alabama Cancer Incidence Rates and Counts, by County, Males, All Races, Combined All Sites Lung Colorectal Prostate Oral Melanoma Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Alabama , , , , , ,819 Autauga , Baldwin , , Barbour Bibb Blount , Bullock ^ ^ ^ ^ Butler Calhoun , Chambers , Cherokee Chilton , Choctaw ^ ^ ^ ^ Clarke Clay Cleburne ^ ^ Coffee , Colbert , Conecuh Coosa ^ ^ ^ ^ Covington , Crenshaw Cullman , Dale , Dallas , DeKalb , Elmore , Escambia , Etowah , Fayette Franklin Geneva Greene ^ ^ ^ ^ Hale ^ ^ Henry Houston , Jackson , Jefferson , , , , Lamar Lauderdale , Lawrence , Lee , Limestone , Lowndes ^ ^ ^ ^ Macon ^ ^ Madison , , , Marengo ^ ^ Marion Marshall , Mobile , , , , Monroe Montgomery , , Morgan , , Perry ^ ^ ^ ^ Pickens ^ ^ Pike Randolph ^ ^ Russell , St. Clair , Shelby , , Sumter ^ ^ ^ ^ Talladega , Tallapoosa , Tuscaloosa , , Walker , Washington Wilcox ^ ^ ^ ^ Winston Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. Rates are for malignant cases only, except for All Sites which contains in situ bladder cases. ^ Statistic not displayed due to fewer than 15 cases. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures 2014

19 Table 5. Alabama Cancer Incidence Rates and Counts, by County, Females, All Races, Combined All Sites Lung Colorectal Breast Cervix Oral Melanoma Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Alabama , , , , , , ,982 Autauga , Baldwin , , Barbour ^ ^ ^ ^ Bibb ^ ^ ^ ^ Blount , Bullock ^ ^ ^ ^ ^ ^ Butler ^ ^ Calhoun , Chambers Cherokee ^ ^ ^ ^ Chilton ^ ^ Choctaw ^ ^ ^ ^ ^ ^ Clarke ^ ^ ^ ^ Clay ^ ^ ^ ^ ^ ^ Cleburne ^ ^ ^ ^ ^ ^ Coffee , Colbert , Conecuh ^ ^ ^ ^ ^ ^ Coosa ^ ^ ^ ^ ^ ^ Covington , Crenshaw ^ ^ ^ ^ Cullman , Dale , Dallas , DeKalb , Elmore , Escambia ^ ^ Etowah , Fayette ^ ^ ^ ^ ^ ^ Franklin ^ ^ ^ ^ Geneva ^ ^ Greene ^ ^ ^ ^ ^ ^ Hale ^ ^ ^ ^ ^ ^ Henry ^ ^ ^ ^ ^ ^ Houston , Jackson , Jefferson , , , , Lamar ^ ^ ^ ^ Lauderdale , Lawrence ^ ^ ^ ^ Lee , Limestone , Lowndes ^ ^ ^ ^ ^ ^ Macon ^ ^ ^ ^ Madison , , Marengo ^ ^ ^ ^ Marion ^ ^ Marshall , Mobile , , , , Monroe ^ ^ ^ ^ ^ ^ Montgomery , , Morgan , Perry ^ ^ ^ ^ ^ ^ Pickens ^ ^ ^ ^ Pike ^ ^ Randolph ^ ^ ^ ^ Russell , St. Clair , Shelby , , Sumter ^ ^ ^ ^ ^ ^ Talladega , Tallapoosa , Tuscaloosa , , Walker , Washington ^ ^ ^ ^ ^ ^ Wilcox ^ ^ ^ ^ ^ ^ Winston ^ ^ Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. Rates are for malignant cases only, except for All Sites which contains in situ bladder cases. ^ Statistic not displayed due to fewer than 15 cases. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures

20 Table 6. Alabama Cancer Incidence Rates and Counts, by County, Males and Females by Race, Combined All Sites Lung Colorectal Oral Melanoma White Black White Black White Black White Black White Black Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Alabama , , , , , , , , , Autauga , ^ ^ ^ ^ Baldwin , , ^ ^ ^ ^ Barbour ^ ^ Bibb ^ ^ ^ ^ Blount , ^ ^ ^ ^ ^ ^ ^ ^ Bullock ^ ^ ^ ^ ^ ^ ^ ^ Butler ^ ^ ^ ^ Calhoun , , ^ ^ Chambers , ^ ^ ^ ^ Cherokee , ^ ^ ^ ^ ^ ^ ^ ^ Chilton , ^ ^ ^ ^ ^ ^ Choctaw ^ ^ ^ ^ ^ ^ Clarke ^ ^ ^ ^ Clay ^ ^ ^ ^ ^ ^ Cleburne ^ ^ ^ ^ ^ ^ ^ ^ Coffee , ^ ^ ^ ^ Colbert , ^ ^ ^ ^ Conecuh ^ ^ ^ ^ Coosa ^ ^ ^ ^ ^ ^ Covington , ^ ^ ^ ^ Crenshaw ^ ^ ^ ^ ^ ^ Cullman , ^ ^ ^ ^ ^ ^ ^ ^ Dale , ^ ^ ^ ^ Dallas , , ^ ^ DeKalb , ^ ^ ^ ^ ^ ^ ^ ^ Elmore , ^ ^ ^ ^ Escambia , ^ ^ ^ ^ Etowah , ^ ^ Fayette ^ ^ ^ ^ Franklin , ^ ^ ^ ^ ^ ^ ^ ^ Geneva , ^ ^ ^ ^ ^ ^ Greene ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Hale ^ ^ ^ ^ ^ ^ Henry ^ ^ ^ ^ Houston , , ^ ^ Jackson , ^ ^ ^ ^ ^ ^ ^ ^ Jefferson , , , , , , Lamar ^ ^ ^ ^ ^ ^ ^ ^ Lauderdale , ^ ^ ^ ^ Lawrence , ^ ^ ^ ^ Lee , , ^ ^ Limestone , ^ ^ ^ ^ Lowndes ^ ^ ^ ^ ^ ^ ^ ^ Macon ^ ^ ^ ^ ^ ^ Madison , , , , ^ ^ Marengo ^ ^ ^ ^ Marion , ^ ^ ^ ^ ^ ^ ^ ^ Marshall , ^ ^ ^ ^ ^ ^ ^ ^ Mobile , , , , ^ ^ Monroe ^ ^ ^ ^ ^ ^ Montgomery , , ^ ^ Morgan , , ^ ^ ^ ^ Perry ^ ^ ^ ^ ^ ^ ^ ^ Pickens ^ ^ ^ ^ Pike ^ ^ ^ ^ Randolph , ^ ^ ^ ^ Russell , ^ ^ St. Clair , ^ ^ ^ ^ Shelby , , ^ ^ Sumter ^ ^ ^ ^ ^ ^ ^ ^ Talladega , , ^ ^ Tallapoosa , ^ ^ Tuscaloosa , , , ^ ^ Walker , ^ ^ ^ ^ Washington ^ ^ ^ ^ Wilcox ^ ^ ^ ^ ^ ^ ^ ^ Winston ,378 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. Rates are for malignant cases only, except for All Sites which contains in situ bladder cases. ^ Statistic not displayed due to fewer than 15 cases. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures 2014

21 Table 7. Alabama Cancer Incidence Rates and Counts, by County, Males by Race, Combined All Sites Lung Colorectal White Black White Black White Black Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Alabama , , , , , ,929 Autauga Baldwin , Barbour Bibb ^ ^ Blount , ^ ^ ^ ^ Bullock Butler Calhoun , Chambers Cherokee ^ ^ ^ ^ Chilton , ^ ^ Choctaw Clarke Clay ^ ^ ^ ^ Cleburne ^ ^ ^ ^ Coffee , Colbert , Conecuh Coosa ^ ^ Covington , Crenshaw ^ ^ ^ ^ Cullman , ^ ^ ^ ^ Dale , Dallas DeKalb , ^ ^ ^ ^ Elmore , Escambia Etowah , Fayette ^ ^ ^ ^ Franklin ^ ^ ^ ^ Geneva ^ ^ ^ ^ Greene ^ ^ Hale Henry ^ ^ Houston , Jackson , ^ ^ ^ ^ Jefferson , , , , , Lamar ^ ^ ^ ^ Lauderdale , Lawrence Lee , Limestone , Lowndes Macon ^ ^ Madison , , Marengo Marion ^ ^ ^ ^ Marshall , ^ ^ ^ ^ Mobile , , , Monroe Montgomery , , Morgan , Perry Pickens Pike Randolph ^ ^ ^ ^ Russell St. Clair , ^ ^ Shelby , Sumter ^ ^ Talladega , Tallapoosa , Tuscaloosa , , Walker , ^ ^ Washington ^ ^ Wilcox Winston ^ ^ ^ ^ ^ ^ Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. Rates are for malignant cases only, except for All Sites which contains in situ bladder cases. ^ Statistic not displayed due to fewer than 15 cases. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures

22 Table 7 (Continued). Alabama Cancer Incidence Rates and Counts, by County, Males by Race, Combined Prostate Oral Melanoma White Black White Black White Black Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Alabama , , , , Autauga ^ ^ ^ ^ Baldwin , ^ ^ ^ ^ Barbour ^ ^ ^ ^ Bibb ^ ^ ^ ^ Blount ^ ^ ^ ^ ^ ^ Bullock ^ ^ ^ ^ ^ ^ ^ ^ Butler ^ ^ ^ ^ Calhoun ^ ^ Chambers ^ ^ ^ ^ Cherokee ^ ^ ^ ^ Chilton ^ ^ ^ ^ Choctaw ^ ^ ^ ^ ^ ^ ^ ^ Clarke ^ ^ ^ ^ Clay ^ ^ ^ ^ ^ ^ Cleburne ^ ^ ^ ^ ^ ^ ^ ^ Coffee ^ ^ ^ ^ Colbert ^ ^ ^ ^ Conecuh ^ ^ ^ ^ Coosa ^ ^ ^ ^ ^ ^ ^ ^ Covington ^ ^ ^ ^ Crenshaw ^ ^ ^ ^ ^ ^ Cullman ^ ^ ^ ^ ^ ^ Dale ^ ^ ^ ^ Dallas ^ ^ DeKalb ^ ^ ^ ^ ^ ^ Elmore ^ ^ ^ ^ Escambia ^ ^ ^ ^ Etowah ^ ^ Fayette ^ ^ ^ ^ Franklin ^ ^ ^ ^ ^ ^ Geneva ^ ^ ^ ^ Greene ^ ^ ^ ^ ^ ^ ^ ^ Hale ^ ^ ^ ^ ^ ^ ^ ^ Henry ^ ^ ^ ^ Houston ^ ^ ^ ^ Jackson ^ ^ ^ ^ ^ ^ Jefferson , , ^ ^ Lamar ^ ^ ^ ^ Lauderdale ^ ^ ^ ^ Lawrence ^ ^ ^ ^ Lee ^ ^ Limestone ^ ^ ^ ^ Lowndes ^ ^ ^ ^ ^ ^ ^ ^ Macon ^ ^ ^ ^ ^ ^ Madison , ^ ^ Marengo ^ ^ ^ ^ ^ ^ ^ ^ Marion ^ ^ ^ ^ ^ ^ Marshall ^ ^ ^ ^ ^ ^ Mobile , , ^ ^ Monroe ^ ^ ^ ^ ^ ^ Montgomery ^ ^ Morgan ^ ^ ^ ^ Perry ^ ^ ^ ^ ^ ^ ^ ^ Pickens ^ ^ ^ ^ ^ ^ ^ ^ Pike ^ ^ ^ ^ Randolph ^ ^ ^ ^ ^ ^ Russell ^ ^ St. Clair ^ ^ ^ ^ Shelby , ^ ^ ^ ^ Sumter ^ ^ ^ ^ ^ ^ ^ ^ Talladega ^ ^ Tallapoosa ^ ^ ^ ^ Tuscaloosa ^ ^ Walker ^ ^ ^ ^ Washington ^ ^ ^ ^ Wilcox ^ ^ ^ ^ ^ ^ ^ ^ Winston ^ ^ ^ ^ ^ ^ Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. Rates are for malignant cases only, except for All Sites which contains in situ bladder cases. ^ Statistic not displayed due to fewer than 15 cases. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures 2014

23 Table 8. Alabama Cancer Incidence Rates and Counts, by County, Females by Race, Combined All Sites Lung Colorectal Breast White Black White Black White Black White Black Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Alabama , , , , , , , ,574 Autauga ^ ^ Baldwin , , Barbour Bibb ^ ^ ^ ^ Blount , ^ ^ ^ ^ ^ ^ Bullock ^ ^ ^ ^ ^ ^ Butler ^ ^ Calhoun , Chambers Cherokee ^ ^ ^ ^ Chilton ^ ^ Choctaw ^ ^ Clarke ^ ^ Clay ^ ^ ^ ^ ^ ^ Cleburne ^ ^ ^ ^ ^ ^ Coffee Colbert , Conecuh ^ ^ Coosa ^ ^ ^ ^ Covington ^ ^ Crenshaw ^ ^ ^ ^ Cullman ,851 ^ ^ ^ ^ ^ ^ ^ ^ Dale ^ ^ Dallas DeKalb , ^ ^ ^ ^ ^ ^ Elmore , Escambia Etowah , Fayette ^ ^ ^ ^ Franklin ^ ^ ^ ^ ^ ^ Geneva ^ ^ ^ ^ Greene ^ ^ ^ ^ Hale ^ ^ Henry ^ ^ Houston , Jackson , ^ ^ ^ ^ ^ ^ Jefferson , , , , , ,886 Lamar ^ ^ ^ ^ Lauderdale , Lawrence ^ ^ Lee , Limestone , Lowndes ^ ^ Macon ^ ^ ^ ^ Madison , , , Marengo Marion ^ ^ ^ ^ ^ ^ Marshall , ^ ^ ^ ^ ^ ^ Mobile , , , , Monroe ^ ^ Montgomery , , Morgan , Perry ^ ^ ^ ^ Pickens Pike Randolph ^ ^ ^ ^ Russell St. Clair , ^ ^ Shelby , , Sumter ^ ^ ^ ^ Talladega , Tallapoosa Tuscaloosa , Walker , ^ ^ ^ ^ Washington ^ ^ ^ ^ Wilcox ^ ^ ^ ^ Winston ^ ^ ^ ^ ^ ^ ^ ^ Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. Rates are for malignant cases only, except for All Sites which contains in situ bladder cases. ^ Statistic not displayed due to fewer than 15 cases. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures

24 Table 8 (Continued). Alabama Cancer Incidence Rates and Counts, by County, Females by Race, Combined Cervix Oral Melanoma White Black White Black White Black Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count Alabama 8.1 1, , , Autauga ^ ^ ^ ^ ^ ^ ^ ^ Baldwin ^ ^ ^ ^ ^ ^ Barbour ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Bibb ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Blount ^ ^ ^ ^ ^ ^ Bullock ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Butler ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Calhoun ^ ^ ^ ^ ^ ^ Chambers ^ ^ ^ ^ ^ ^ Cherokee ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Chilton ^ ^ ^ ^ ^ ^ ^ ^ Choctaw ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Clarke ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Clay ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Cleburne ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Coffee ^ ^ ^ ^ ^ ^ ^ ^ Colbert ^ ^ ^ ^ ^ ^ Conecuh ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Coosa ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Covington ^ ^ ^ ^ ^ ^ Crenshaw ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Cullman ^ ^ ^ ^ ^ ^ Dale ^ ^ ^ ^ ^ ^ ^ ^ Dallas ^ ^ ^ ^ ^ ^ ^ ^ DeKalb ^ ^ ^ ^ ^ ^ Elmore ^ ^ ^ ^ ^ ^ Escambia ^ ^ ^ ^ ^ ^ ^ ^ Etowah ^ ^ ^ ^ ^ ^ Fayette ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Franklin ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Geneva ^ ^ ^ ^ ^ ^ ^ ^ Greene ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Hale ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Henry ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Houston ^ ^ ^ ^ Jackson ^ ^ ^ ^ ^ ^ Jefferson ^ ^ Lamar ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Lauderdale ^ ^ ^ ^ ^ ^ Lawrence ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Lee ^ ^ ^ ^ ^ ^ Limestone ^ ^ ^ ^ ^ ^ Lowndes ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Macon ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Madison ^ ^ Marengo ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Marion ^ ^ ^ ^ ^ ^ ^ ^ Marshall ^ ^ ^ ^ ^ ^ Mobile ^ ^ Monroe ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Montgomery ^ ^ Morgan ^ ^ ^ ^ ^ ^ Perry ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Pickens ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Pike ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Randolph ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Russell ^ ^ ^ ^ ^ ^ ^ ^ St. Clair ^ ^ ^ ^ ^ ^ Shelby ^ ^ ^ ^ ^ ^ Sumter ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Talladega ^ ^ ^ ^ Tallapoosa ^ ^ ^ ^ Tuscaloosa ^ ^ ^ ^ Walker ^ ^ ^ ^ ^ ^ Washington ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Wilcox ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Winston ^ ^ ^ ^ ^ ^ ^ ^ Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. Rates are for malignant cases only, except for All Sites which contains in situ bladder cases. ^ Statistic not displayed due to fewer than 15 cases. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures 2014

25 Cancer Mortality Tables Table 9. Alabama Cancer Mortality Rates and Counts, by Site, Race, and Sex, Combined Male and Female Male All Races White Black All Races White Black Rate Count Rate Count Rate Count Rate Count Rate Count Rate Count All Malignant Cancers , , , , , ,303 Oral Cavity and Pharynx 2.9 1, , , Digestive System , , , , , ,267 Esophagus 4.0 2, , , , Stomach 3.6 1, , , Small Intestine Colon and Rectum , , , , , ,270 Colon Excluding Rectum , , , , , ,037 Rectum and Rectosigmoid Junction 3.1 1, , Anus, Anal Canal, and Anorectum Liver and Intrahepatic Bile Duct 5.7 2, , , , Gallbladder Pancreas , , , , , Other Digestive Organs Respiratory System , , , , , ,972 Larynx Lung and Bronchus , , , , , ,749 Bones and Joints Soft Tissue Including Heart Skin Excluding Basal and Squamous 3.7 1, , , , Melanoma of the Skin 2.8 1, , ^ ^ Other Non-Epithelial Skin Breast , , , Female Genital System * * * * * * * * * * * * Cervix Uteri * * * * * * * * * * * * Corpus and Uterus, NOS * * * * * * * * * * * * Corpus Uteri * * * * * * * * * * * * Uterus, NOS * * * * * * * * * * * * Ovary * * * * * * * * * * * * Vagina * * * * * * * * * * * * Vulva * * * * * * * * * * * * Other Female Genital Organs * * * * * * * * * * * * Male Genital System * * * * * * , , ,998 Prostate * * * * * * , , ,975 Testis * * * * * * ^ ^ Penis * * * * * * Other Male Genital Organs * * * * * * ^ ^ ^ ^ ^ ^ Urinary System 8.0 4, , , , Urinary Bladder 3.9 1, , , , Kidney and Renal Pelvis 4.0 2, , , , Ureter ^ ^ ^ ^ Other Urinary Organs ^ ^ ^ ^ Eye and Orbit ^ ^ ^ ^ Brain and Other Nervous System 4.6 2, , , , Endocrine System Thyroid Other Endocrine Including Thymus ^ ^ Lymphoma 7.0 3, , , , Hodgkin Lymphoma Non-Hodgkin Lymphoma 6.6 3, , , , Myeloma 4.1 2, , , Leukemia 7.5 3, , , , Lymphocytic Leukemia 2.0 1, Acute Lymphocytic Leukemia Chronic Lymphocytic Leukemia Myeloid and Monocytic Leukemia 3.1 1, , Acute Myeloid Leukemia 2.5 1, , Chronic Myeloid Leukemia ^ ^ Other Leukemia 2.4 1, Miscellaneous Malignant Cancer , , , , , ,084 Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. ^ Statistic not displayed due to fewer than 15 deaths. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures

26 Table 9 (Continued). Alabama Cancer Mortality Rates and Counts, by Site, Race, and Sex, Combined Female All Races White Black Rate Count Rate Count Rate Count All Malignant Cancers , , ,424 Oral Cavity and Pharynx Digestive System , , ,759 Esophagus Stomach Small Intestine Colon and Rectum , , ,232 Colon Excluding Rectum , , ,060 Rectum and Rectosigmoid Junction Anus, Anal Canal, and Anorectum ^ ^ Liver and Intrahepatic Bile Duct 3.6 1, Gallbladder Pancreas 9.6 2, , Other Digestive Organs Respiratory System , , ,933 Larynx Lung and Bronchus , , ,892 Bones and Joints Soft Tissue Including Heart Skin Excluding Basal and Squamous Melanoma of the Skin Other Non-Epithelial Skin Breast , , ,953 Female Genital System , , ,242 Cervix Uteri Corpus and Uterus, NOS 3.4 1, Corpus Uteri Uterus, NOS Ovary 8.9 2, , Vagina Vulva ^ ^ Other Female Genital Organs Male Genital System * * * * * * Prostate * * * * * * Testis * * * * * * Penis * * * * * * Other Male Genital Organs * * * * * * Urinary System 4.6 1, , Urinary Bladder Kidney and Renal Pelvis Ureter ^ ^ Other Urinary Organs ^ ^ ^ ^ ^ ^ Eye and Orbit ^ ^ ^ ^ ^ ^ Brain and Other Nervous System 3.8 1, Endocrine System Thyroid Other Endocrine Including Thymus Lymphoma 5.7 1, , Hodgkin Lymphoma Non-Hodgkin Lymphoma 5.4 1, , Myeloma Leukemia 5.6 1, , Lymphocytic Leukemia Acute Lymphocytic Leukemia ^ ^ Chronic Lymphocytic Leukemia Myeloid and Monocytic Leukemia Acute Myeloid Leukemia Chronic Myeloid Leukemia ^ ^ Other Leukemia Miscellaneous Malignant Cancer , , Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. ^ Statistic not displayed due to fewer than 15 deaths. Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures 2014

27 Table 10. Trends in Alabama Cancer Mortality, Selected Sites, Females Breast P-Value Cervix P-Value Rate/Trend SE Lower CI Upper CI Rate/Trend SE Lower CI Upper CI Total PC -2.3 Total PC -9.5 Total APC Total APC Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Males Males and Females Prostate P-Value All Sites P-Value Rate/Trend SE Lower CI Upper CI Rate/Trend SE Lower CI Upper CI Total PC Total PC -6.1 Total APC Total APC -1.7* Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Males and Females Colorectal P-Value Lung P-Value Rate/Trend SE Lower CI Upper CI Rate/Trend SE Lower CI Upper CI Total PC Total PC -8.1 Total APC -3.7* Total APC Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Melanoma P-Value Oral P-Value Rate/Trend SE Lower CI Upper CI Rate/Trend SE Lower CI Upper CI Total PC 10.7 Total PC -7.5 Total APC Total APC Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard; Confidence intervals are 95% for rates and trends. Percent changes were calculated using 1 year for each end point; APCs were calculated using weighted least squares method. *The APC is significantly different from zero (p<0.05). Source: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Cancer Facts & Figures

28 National Comparison Tables Table 11. Alabama and United States Cancer Incidence Rates, by Site, Race, and Sex, * Males and Females Alabama United States All Races White Black All Races White Black All Sites # Lung and Bronchus 74.5 # 76.9 # Colon and Rectum 46.5 # 44.3 # 55.2 # Melanoma of the Skin 21.0 # 26.9 # Males Alabama United States All Races White Black All Races White Black All Sites # # # Lung and Bronchus # # # Colon and Rectum 56.0 # 53.4 # 67.9 # Melanoma of the Skin 28.2 # 35.1 # Prostate # # Females Alabama United States All Races White Black All Races White Black All Sites 398.7^ 404.6^ 380.3^ Lung and Bronchus # 39.8^ Colon and Rectum Melanoma of the Skin # Breast 119.1^ 116.8^ Cervix 8.6 # Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. *All rates are for malignant cases only, except the rates for All Sites which includes bladder cancer in situ. # The incidence rate for Alabama is significantly higher than the incidence rate for the United States (p<0.05). ^ The incidence rate for Alabama is significantly lower than the incidence rate for the United States (p<0.05). Sources: Alabama Data: Alabama Statewide Cancer Registry (ASCR), Data Years: United States Data: NAACCR CINA+ Online, Data Years: Table 12. Alabama and United States Cancer Mortality Rates, by Site, Race, and Sex, Males and Females Alabama United States All Races White Black All Races White Black All Sites # # # Lung and Bronchus 60.0 # 61.7 # Colon and Rectum 17.8 # # Melanoma of the Skin # Males Alabama United States All Races White Black All Races White Black All Sites # # # Lung and Bronchus 86.8 # 86.2 # 91.1 # Colon and Rectum 22.3 # # Melanoma of the Skin # Prostate 28.6 # # Females Alabama United States All Races White Black All Races White Black All Sites ^ 169.5^ Lung and Bronchus 40.7 # 43.5 # 30.9^ Colon and Rectum ^ Melanoma of the Skin Breast ^ Cervix 3.0 # # Rates are per 100,000 and age-adjusted to the 2000 US (19 age groups) standard. # The mortality rate for Alabama is significantly higher than the rate for United States (p<0.05). ^ The mortality rate for Alabama is significantly lower than the rate for United States (p<0.05). Sources: Alabama Data: Alabama Statewide Cancer Registry (ASCR), Data Years: United States Data: CDC WONDER, Data Years: Alabama Cancer Facts & Figures 2014

29 Health Risk and Cancer Screening Behaviors Tables Table 13. Percentage of Tobacco Use, Adults (2013) and High School Students (2013), Alabama and the US Current Cigarette Smoking Alabama United States Total Adults Male Adults Female Adults Low Education White Black Total High School Students Male High School Students Female High School Students White High School Students Black High School Students Source: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System, Centers for Disease Control and Prevention. Table 14. Percentage of Colorectal Cancer Screening, Adults 50 and Older, Alabama and the US, 2012 Sigmoidoscopy/Colonoscopy Alabama United States Total Adults Male Adults Female Adults White Black Low Education Fecal Occult Blood Test in the Past 2 Years Alabama United States Total Adults Male Adults Female Adults White Black Low Education Source: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. Table 15. Percentage of Breast Cancer Screening, Women 40 and Older, Alabama and the US, 2012 Mammogram in the Past 2 Years Alabama United States 40 Years and Older White Black Low Education Source: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. Alabama Cancer Facts & Figures

30 Table 16. Percentage of Prostate Cancer Screening, Men 50 and Older, Alabama and the US, 2012 PSA within the Past 2 Years Alabama United States Years Old Years Old Years and Older White Black, 45 Years and Older Low Education Source: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. Table 17. Percentage of Cervical Cancer Screening, Women 18 and Older, Alabama and the US, 2012 Pap Test within the Past 3 Years Alabama United States Total 18 Years and Older White Black Low Education Source: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. Table 18. Percentage of Fruit and Vegetable Intake, Adults 18 and Older, Alabama and the US, 2013 Consuming Vegetables Less than One Time Daily Alabama United States Total Male Female White Black Low Education Consuming Fruit Less than One Time Daily Alabama United States Total Male Female White Black Low Education Source: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. Table 19. Percentage of Physical Activity, Adults 18 and Older, Alabama and the US, 2013 Participated in 150 Minutes Aerobic Physical Activity per Week Alabama United States Total Male Female White Black Low Education Source: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. Table 20. Percentage of Overweight*, Adults 18 and Older, Alabama and the US, 2013 Overweight Alabama United States Total Male Female White Black Low Education Source: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. *BMI 25 and over. 26 Alabama Cancer Facts & Figures 2014

31 Sources 1. American Cancer Society. Cancer Facts & Figures Atlanta: American Cancer Society; Alabama Statewide Cancer Registry (ASCR), Data Years: (Incidence and Mortality). Alabama Department of Public Health. 3. Alabama Data: Alabama Statewide Cancer Registry (ASCR), Data Years: Alabama Department of Public Health. US Data: NAACCR CINA+ Online, Data Years: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), National Vital Statistics System (NVSS), wonder.cdc.gov/cancer.html. Data Years: Behavioral Risk Factor Surveillance System, Centers for Disease Control and Prevention. Technical Notes International Classification of Diseases (ICD) codes used for this report were based on the North American Association of Central Cancer Registries (NAACCR) list for incidence and mortality. The International Classification of Diseases for Oncology, Third Edition (2000) was used for incidence data. The International Classification of Diseases, Tenth Revision, Clinical Modification (2003) was used for mortality data. The 95% confidence intervals were calculated for incidence and mortality data and used to determine the level of significance when comparing two rates. If the confidence intervals overlapped, it was determined that no difference existed between the two rates. MATERIALS & METHODS Population Estimates The population estimates for the denominators of incidence and mortality rates are race-specific (all races, white, black) and sex-specific county population estimates. The county population estimates were incorporated into the National Cancer Institute s (NCI s) SEER*Stat software to calculate cancer incidence and mortality rates. The SEER*Stat population estimates are a slight modification of the annual time series of July 1 county population estimates (by age, sex, and race) produced by the Population Estimates Program of the US Bureau of the Census with support from NCI through an interagency agreement. Data Sources Data from cancer registries, health information departments, histopathologic laboratories, and physician offices were reported to the Alabama Statewide Cancer Registry (ASCR) as of November 1, For cancer cases diagnosed during , the ASCR considered as reportable all incident cases with a behavior code of 2 (in situ, non-invasive) or 3 (invasive, primary site only) in the International Classification of Diseases for Oncology (ICDO) (3rd edition), with the exception of in situ cancer of the cervix. Basal and squamous cell carcinomas of the skin are also excluded, with the exception of those on the skin of the genital organs. The primary source of cancer incidence data is medical records. Staff at health care facilities abstract cancer incidence data from patients medical records, enter the data into the facility s own cancer registry if it has one, and then send the data to the ASCR. All reporting sources collect data using uniform data items and codes as documented by the North American Association of Central Cancer Registries. This uniformity means that data items collected by all reporting sources are comparable. For this report, information on primary cancer sites was coded according to the appropriate ICDO edition and was grouped according to revised SEER recodes dated January 27, 2003, which define standard groupings of primary cancer sites. The January 2003 SEER recodes were used to ensure consistent site-type definitions over time and consistency with other published cancer incidence and mortality data. Invalid site codes were excluded from the analysis. Age-adjusted Incidence Rates Because the occurrence of many cancers increases with age and because the age distribution of a population (i.e., the number of people in particular age categories) can change over time and can be different in different geographic areas, researchers age adjust incidence rates so that they can make a valid comparison between one year s rates and those of another year or between one geographic area s rates and those of another area. Age adjusting the rates ensures that differences in incidence from one year to another or from one geographic area to another are not due to differences in age distribution. The standard population used to age adjust the rates for this report is the 2000 US standard population, in accordance with a 1998 Department of Health and Human Services recommendation. The 2000 US standard population is based on the proportion of the 2000 population in specific age groups. The proportions of the 2000 population in these age groups serve as weights for calculating age-adjusted incidence rates. Because national publications tend to exclude in situ cases when calculating incidence rates except for bladder cancer, the ASCR has included a new table Alabama Cancer Facts & Figures

32 (Table 11, page 24) that calculates incidence rates in the same fashion. This table was added to facilitate an accurate comparison between Alabama and United States incidence rates. Moreover, the ASCR incidence rates and their associated counts presented in Tables 1-8 are based on the 10 most recent years of data available and exclude in situ cases for all sites except urinary bladder. The ASCR chose to make this change to exclude in situ cases to bring this publication into line with the national publication standard of excluding in situ cases even if doing so prohibits direct comparisons to be made to previous editions of Alabama Cancer Facts & Figures. Age-adjusted Mortality Rates Mortality data for Alabama was obtained from the Alabama Department of Public Health Center for Health Statistics, and age-adjusted rates were calculated using the 2000 US standard population. Prior to the release of Alabama Cancer Facts & Figures 2007, cancer deaths of Alabama residents that occurred outside of the state were omitted from the rates. Beginning with Alabama Cancer Facts & Figures 2007, these deaths were included in the rate calculations. Annual Percentage Change (APC) The annual percentage change (APC) is a summary statistic that represents the average rate of change in a rate over a defined time period and is used to measure trends over time. The APC is calculated by fitting a least squares regression line to the natural logarithm of the rates using the calendar year as a regressor variable. Interpreting the Data Published age-adjusted cancer incidence and mortality rates for years before 1999 were calculated using standard populations other than the 2000 US standard population. Beginning with the publication of data for the 1999 diagnosis year, or year of death, cancer incidence and mortality rates were age adjusted to the 2000 US standard population. This change was motivated by a need to standardize age-adjustment procedures across publications and to update the calculation of age-adjusted rates to more closely reflect the current age distribution of the US population and the current burden of cancer. Because of the aging of the US population, the 2000 US standard population gives more weight to older age categories than did previous standard populations. Caution should be used when comparing the data published here with cancer incidence and mortality rates adjusted to standard populations other than the 2000 US standard population. Geographic variation in incidence and mortality rates may be the result of regional differences in the exposure of the population to known or unknown risk factors. Differences may arise because of differences in sociodemographic characteristics of the populations (e.g., age, race, or ethnicity, geographic region, urban, or rural residence), screening use, health-related behaviors (e.g., behaviors related to tobacco use, diet, physical activity), exposure to cancer-causing agents, or factors related to registry operations (e.g., completeness, timeliness, specificity in coding cancer sites). Work continues to ensure the reporting of high-quality data. Please note that differences in registry database completeness and data quality do influence the estimated cancer incidence rates. Because 2012 cases were 95 percent complete at the time of this publication, some rates, especially all sites combined, may vary slightly from the true or final rates for the Alabama population. The rates presented here have not been adjusted for completeness differences across the database. The ASCR may update the previous years data as cancer registries submit data for the new diagnosis year and additional cases from the previous diagnosis years. Users of cancer incidence data should be mindful of this issue for all data used in their comparisons. Race information reported to the ASCR is not self-reported by the patient. Information on race is abstracted from medical records, coded according to standard procedures and then grouped into standard race groupings. In this Alabama Cancer Facts & Figures report, cancer incidence and mortality data are presented for all races combined and for white and black populations in Alabama. 28 Alabama Cancer Facts & Figures 2014

33 American Cancer Society Quality of Life Programs For the nearly 1.7 million cancer patients expected to be diagnosed in 2014 and the approximately 14 million US cancer survivors, the American Cancer Society is available anytime, day or night, to offer free information, programs, services, and community referrals to patients, survivors, and caregivers to help them make decisions through every step of a cancer experience. These resources are designed to help people facing cancer on their journey to getting well. Information, 24 Hours a Day, Seven Days a Week The American Cancer Society is available 24 hours a day, seven days a week online at cancer.org and by calling Callers are connected with a cancer information specialist who can help them locate a hospital, understand cancer and treatment options, learn what to expect and how to plan, help address insurance concerns, find financial resources, find a local support group, and more. The Society can also help people who speak languages other than English or Spanish find the assistance they need, offering services in 170 languages in total. Information on every aspect of the cancer experience, from prevention to survivorship, is also available through cancer.org, the organization website. The site contains in-depth information on every major cancer type, as well as on treatments, side effects, caregiving, and coping. The Society also publishes a wide variety of pamphlets and books that cover a multitude of topics, from patient education, quality of life, and caregiving issues to healthy living. Visit cancer.org/bookstore for a complete list of Society books available to order. The Society publishes three peer-reviewed journals for health care providers and researchers: Cancer, Cancer Cytopathology, and CA: A Cancer Journal for Clinicians. Visit acsjournals.com for more information about the journals and their content. who experience language or health literacy barriers, or those with limited resources. The American Cancer Society Patient Navigator Program was designed to reach those most in need. The largest oncology-focused patient navigator program in the country, it has specially trained patient navigators at 121 cancer treatment facilities across the nation. Patient navigators work in cooperation with patients, family members, caregivers, and facility staff to connect patients with information, resources, and support to decrease barriers and ultimately to improve health outcomes. In 2013, approximately 77,000 people relied on the Patient Navigator Program to help them through their diagnosis and treatment. The Society collaborates with a variety of organizations, including the National Cancer Institute s Center to Reduce Cancer Health Disparities, the Center for Medicare and Medicaid Services, numerous cancer treatment centers, and others to implement and evaluate this program. Transportation to Treatment Cancer patients cite transportation to and from treatment as a critical need, second only to direct financial assistance. The American Cancer Society Road To Recovery program matches these patients with specially trained volunteer drivers. This program offers patients an additional key benefit of companionship and moral support during the drive to medical appointments. In 2013, the Society provided more than 1.48 million transportation services to more than 283,000 constituents. Day-to-day Help and Emotional Support The American Cancer Society can help cancer patients and their families find the resources they need to make decisions about the day-to-day challenges that can come from a cancer diagnosis, such as transportation to and from treatment, financial and insurance needs, and lodging when having to travel away from home for treatment. The Society also connects people with others who have been through similar experiences to offer emotional support. Help Navigating the Health Care System Learning how to navigate the cancer journey and the health care system can be overwhelming for anyone, but it is particularly difficult for those who are medically underserved, those Alabama Cancer Facts & Figures

34 Lodging during Treatment When someone diagnosed with cancer must travel away from home for the best treatment, where to stay and how to afford accommodations are immediate concerns and can sometimes affect treatment decisions. American Cancer Society Hope Lodge facilities provide free, homelike, temporary lodging for patients and their caregivers close to treatment centers, thereby easing the emotional and financial burden of finding affordable lodging. In 2013, the 31 Hope Lodge locations provided approximately 265,000 nights of free lodging to nearly 43,000 patients and caregivers saving them nearly $38 million in lodging expenses. The Society also provided discounted lodging to many patients and caregivers through arrangements with hotels in some communities without a Hope Lodge facility. Breast Cancer Support Through the American Cancer Society Reach To Recovery program, trained breast cancer survivor volunteers provide one-on-one support, information, and resource referrals to people facing breast cancer. Patients are matched with a volunteer who has had a similar breast cancer experience as well as other similar characteristics. These volunteers will meet oneon-one, either in person, by telephone, or via , with women anytime throughout their breast cancer experience. Cancer Education Classes The I Can Cope online educational program is available free to people facing cancer and their families and friends. The program consists of self-paced classes that can be taken anytime, day or night. People are welcome to take as few or as many classes as they like. Among the topics offered are information about cancer, managing treatments and side effects, healthy eating during and after treatment, communicating with family and friends, finding resources, and more. Visit cancer.org/onlineclasses to learn more about online classes. Hair-loss and Mastectomy Products Some women wear wigs, hats, breast forms, and special bras to help cope with the effects of mastectomy and hair loss. The American Cancer Society s tlc Tender Loving Care magazine/ catalog offers informative articles and a line of products to help women who are battling cancer restore their appearance and self-esteem. The tlc products and catalogs may be ordered online at tlcdirect.org or by calling All proceeds from product sales go back into the Society s programs and services for patients and survivors. Help with Appearance-related Side Effects of Treatment The Look Good Feel Better program is a collaboration of the American Cancer Society, the Personal Care Products Council Foundation, and the Professional Beauty Association that helps women learn beauty techniques to restore their self-image and cope with appearance-related side effects of cancer treatment. This free program engages certified, licensed beauty professionals trained as Look Good Feel Better volunteers to provide tips on makeup, skin care, nail care, and head coverings. Information and materials are also available for men and teens. To learn more, visit the Look Good Feel Better website at lookgoodfeelbetter.org or call LOOK ( ). Finding Hope and Inspiration People with cancer and their loved ones do not have to face their cancer experience alone. They can connect with others who want support through the American Cancer Society Cancer Survivors Network program. The free online community created by and for people living with cancer and their families, which is at csn.cancer.org, enables people to get and give support, connect with others, find resources, and tell their own story through personal expressions like music and art. 30 Alabama Cancer Facts & Figures 2014